News: CMS proposal aims to reduce Medicare appeals backlog

The backlog of Medicare appeals could be cleared by 2021, according to a proposed rule released by CMS and the U.S. Department of Health & Human Services on June 28.

As of April 30 2016, the Office of Medicare Hearings and Appeals (OMHA) has more than 750,000 pending appeals, which was called out in a recent Government Accountability Office report. The proposal would expand the number of available OMHA adjudicators to increase its capacity by 15,000 appeals per year.

The proposed rule would revise the minimum payment necessary to file an appeal and eliminate some parts of the appeals process entirely. For example, the agency would allow attorney adjudicators to issue decisions, dismissals, and remands when an Administrative Law Judge (ALJ) is not required to necessary to render a decision.

The rule would also give the Departmental Appeals Board (DAB) the ability to designate certain decisions as precedential, giving potential appellants a body of final decisions to review to decide whether to pursue an appeal. All decisions would be published in the Federal Register and accessible online. The decisions would be binding for CMS and associated contractors for initial determinations, redeterminations, and reconsiderations, but the precedent would only apply to those decisions specifically designated by the DAB.

A Senate subcommittee approved a spending bill that includes funds to address the backlog, according to a government statement. Comments are due to CMS by August 29.